亞開(kāi)行-支持蒙古醫(yī)療融資改革：經(jīng)驗(yàn)、教訓(xùn)和未來(lái)方向英

INMONGOLIAnueMandaluyongCityMetroManilaPhilippinesTelFax62444PublicationStockNo.WPS220609-3DOI:/10.22617/WPS220609-3areaThisworkisavailableundertheCreativeCommonsAttribution3.0IGOlicense(CCBY3.0IGO)/licenses/by/3.0/igo/.Byusingthecontentofthispublication,youagreetobeboundeadtheprovisionsandtermsofuseat/terms-use#openaccess.utedresearchandpolicystudiesundertakenbytheEastAsiaDepartmentofcepersonsTheseriesdealswithkeyeconomiclyticalormethodologicalissuesrelatingtoprojectprogramsstrengthenanalyticalrigorandqualityofADBscountrypartnershipstrategiescountryoperationsandimprovethequalityandavailabilityofstatisticaldataanddevelopmentindicatorsformonitoringdevelopmenteffectiveness.tCONTENTSACKNOWLEDGMENTSYORMA.HealthCareinMongoliabeforethe1990sB.Health-CareFinancinginMongoliabeforethe1990sA.SupportingtheEstablishmentoftheSocialHealthInsuranceOLIAsQ8ACKNOWLEDGMENTSMOHout-of-pocketCURRENCYEQUIVALENTS(asof15December2022)ollapsethatsignificantlyreducedtheoverallstatebudgetandallocationofeancingmodeltotheoutputorientedmodelinuseinthatisbettersuitedtotherealitiesofsdeliveredseveralsignificantresultsnfundingallocatedforprimaryhealthcarecomparedwiththefundingallocatedforoversizedandrthyentrallyplannedhealthsectormodelwasnotableforitsprovisionoffreeandtives1DescribedastheSemashkomodel,whichexistedintheformerSovietUnion(I.Sheiman.2013.RockyRoadfromthespitalsalsoprovidedantenatalandpostnatalcareandminorsurgeryoperatedmaternityrestromremoteesofsoumhospitalsfootnotethesupervisionofamedicaldoctorfromthesoumhospital(footnote2).egeneralrgencycaremaghasapopulationof(NationalStatisticalOfficeofMongolia.PopulationofMongolia,byAimag,2021).andtheadultpopulation(footnote2).calTheterminationoftradearrangementswiththemembersoftheCouncilforMutualEconomicltionsitbecamedifficulttomaintainfreehealthcarethroughstate13TheorganizationwasestablishedinJanuary1949tofacilitateandcoordinatetheeconomicdevelopmentofthesocialisttriesbelongingtotheSovietblocditurenesdFormalsectorcontributionsfundedmuchofthetotalincomeofthehealthinsurancefund,whichy16Itsoonbecameclearthatthebudgetaryfinancingmechanismandretroactivepaymentmechanismtoprovidersunderhealthinsurancedidnotprovideincentivestocontrolcost.Torestrictsuchincentivesandcontrolhospitalcosts,fixedandvariablecostcomponentsofpublichospitalswereseparatedin1997,andthehealthinsurancefundbecameresponsibleforonlyhealth-care-relatedvariablecosts.Thefixed-costcomponentofhospitalswaslinkedtobudgetaryfinancing(footnote11(a)).17Vulnerablegroupsofpopulationincludechildrenunder16,pensioners,womentakingcareofchildrenunder2,citizensneedingsocialassistancedisabled,orphans,singleoldpersons,andothers),full-timestudents,andherders.Since1997,nelce20Thisincludedservicesforpregnantwomenandchildren;infectiousandchronicdiseasessuchastuberculosis,brucellosis,rancemanagement(footnote11(a)).Gradually,thegovernmentdecidedtotransfertheadministrativedetransition—whenthegovernmentdidnothavemuchexpertiseorresources—theADBtechnicalsncebasedonrisk-adjustedcapitation.ChangesmadetotheHealthLawin2006shiftedthefundingofprimaryhealthfromstemsinoFigure2:SourcesofFundingforHealthCareinMongolia,2005–2019(%)80.070.060.050.040.030.020.010.00.069.466.569.726.923.605201020152019apparent.Overallparticipationdeclinedfrominitiallevelsof95%toaround80%by2006.23TheionsesTheformalsectoralsocontinuedtobeburdenedbycopaymentsandincreasedstsonoffinancingsourcesalsoaffectedtheprocessofpurchasinghospitalservicesrnorofficestoconcludeagreementswithhospitalsundertheirjurisdiction.ThefinancingagreementsreflectedannualfinancingthresholdsandincludedsomeperformanceindicatorsAstheMOHors24Merriam-WebsterOnlinedefinesDRGsaspaymentcategoriesthatareusedtoclassifypatientsforthepurposeofreimbursinghospitalsforeachcaseineachcategorywithafixedfeeregardlessoftheactualcostsincurred.25Itstartedin2006with22diagnosticclustersdescribedaccordingtotheinternationalclassificationofdiseases(ICD-10),oMinistryofLocalTertiaryhospitalsMinistryofLocalTertiaryhospitalssubsidized1.Resource OiceAimagAimag,districtgeneralhospitalsarequestedADBtoresumeitssupportforstrengtheningtheentolent7GovernmentofMongolia,MinistryofHealth.2010.ThirdHealthSectorDevelopmentProgram.HealthFinancingModelforarttoertoadwiththeHIGOactingasapurchaseronbehalfofbothehealthinsurancefundFigureTheMOFexecutedaMON31ADB.2018.TechnicalAssistancetoMongoliaforImprovingHealthCareFinancingforUniversalHealthCoverage.Manila(TA9701-MON).ogrammaticApproachand33ADB,andGovernmentofMongolia,MinistryofFinanceandMinistryofHealth.2021.MidtermReviewReport:Mongolia—TAMONoAlltypesoftaxincomepooledtothecentralbudgetareallocatedbytheMinistryofFinancetodiferentsectors.AlltypesoftaxincomepooledtothecentralbudgetareallocatedbytheMinistryofFinancetodiferentsectors.contract rformance?TheHealthInsuranceGeneralOicecollectsers(StateBudget) eHealthandinvestmentassistancefromADBtoaddressthefragmentationofthehealth-carefinancingdcingmodelproposedbytheTHSDPyaddingsomeomittedservices(outpatient,daycare,andsomediagnosticservices)inthehealthtrivedtointroducemoreeffectivebilityinnsllysedesssImprovingcontractingandproviderselection.Alongwiththeintroductionofnewoutput-basedhiftfrompassivefinancingtoactiveatewasequivalenttoperpersonperyear37TheaverageannualpercapitapaymentforfamilyhealthcentersisMNT60,000asofApril2022(NationalCouncilfor40GovernmentofMongolia,MinistryofHealth;ADB;andGFAConsultingGroup.2019.Mongolia:StrengtheningHospitalAutonomy.Finalreport.Ulaanbaatar(TA9037MON).41NationalCouncilforHealthInsurance.2022.ResolutionNo.01:AboutApprovingRevisedList,PaymentTariffs,PaymentoedonertheastudytoinvestigatetheextentoffinancialbarriersandimplicationsofOOPexpenditureforthethresholdperperson,whichisessentialforpeoplewithsevereconditionsandlowincome.47Thehehhealthfinancingreform.Inadditiontofinancingthroughthestatebudget,thehealthinsuranceeantMONementceilingofuptoMNT2millionperpersonperyearforhospitalizationandMNT165,000perpersonperquarterfordiagnostictests.gePaymentMethodPaymentMethodSoum(i)Health(ii)Centers(iii)(iv)(v)(vi)(vii)(viii)(ix)(x)(i)(ii)(iii)(iv)(i)(ii)(iii)(iv)(v)(vi)(vii)(i)(ii)(iii)(iv)(i)(ii)(iii)(iv)lth(i)(ii)(iii)(iv)(i)(ii)(iii)(iv)(i)(ii)(iii)(iv)(i)(ii)(iii)(iv)oPaymentMethodPaymentMethod(i)(ii)(iii)(iv)(v)(vi)(i)(ii)(iii)(iv)(v)(vi)(vii)(viii)(i)(ii)Private(i)(ii)tariffs)(i)(ii)(iii)(iv)(v)(vi)(vii)gpeopleInsufficientpublicfunding.ThisremainedamajorchallengeforthehealthsysteminMduct./data/gho/data/indicators/indicator-details/GHO/current-health-expenditure-(che)-as-900800700600500400300200000%billionMNT2.00billionMNT2.00.02005201020152016201720182019hexpenditurebillionMNTAsproportionofGDPeMongolianpopulationinthehealthandimpoverishment.TheWorldHealthOrganizationHealthAccountGlobalHealthExpenditureOOPexpenditureinpublichospitals.52DespitegovernmenteffortstosubsidizethecostofmostetoreMoreeffectiveuseofavailableresources.Downsizingthephysicalinfrastructureofthehospital49Healthaccountsareawayforcountriestomonitorhealthspendingacrossmultiplestreams,regardlessoftheentityorinstitutionthatfinancedandmanagedthatspending.50WorldHealthOrganization.GlobalHealthExpenditureDatabase./nha/database/country_profile/Index/en(accessed28November2022).in52J.Dorjdagvaetal.2021.DoesSocialHealthInsurancePreventFinancialHardshipinMongolia?InpatientCare:ACaseinoesulatedbasedonthebestinternationalshrdstrategicpurc